Family-focused practices in addictions: a scoping review protocol

Abstract

Introduction

Families are significantly impacted by addictions and family involvement in treatment can reduce the harms and can also improve treatment entry, treatment completion and treatment outcomes for the individual coping with an addiction. Although the benefits of family-focused practices in addictions have been documented, services continue to have an individual focus and research on this topic is also limited. The objective of this study is to map the extent, range and nature of evidence available examining family interventions in addictions and identify gaps to guide future research, policy and practice.

Methods and analysis

This is a scoping review using the five-stage framework developed by Arksey and O’Malley. We will include published and unpublished empirical studies focusing on any type of family interventions in addiction treatment between 2000 and the present in English or French. A reviewer will search for literature that meets the inclusion criteria through the following electronic databases: MEDLINE, PsycINFO and Social Services Abstracts. For a comprehensive search, we will also hand-search reference lists, web sites and key journals. Data will be charted and sorted using a thematic analysis approach.

Ethics and dissemination

This review will be the first to examine all forms of family-focused practices for both substance use and problem gambling treatment for adults. It will provide information about existing service provisions and gaps in practice. This review can be used to start moving towards the development of best practices for families in addiction treatment. The results will be disseminated through a peer-reviewed journal and at mental health and addiction conferences.

Strengths and limitations of this study.

• This scoping review will be the first to examine family-focused practices in both substance use and gambling adult treatment.

• Inclusion criteria are broad (English and French, peer-reviewed and grey literature) and this will give the review breadth and comprehensiveness.

• The studies included in the review will not be appraised for quality.

• Rigour will be enhanced through the use of a data charting form and a transparent, iterative team approach.

Introduction

There are more than 29.5 million individuals worldwide who have a drug use problem¹ and 76 million people with alcohol use disorder.² More recently, there has been more research on behavioural addictions and studies show that problem gambling affects 0.12%–5.8% of people across five continents.³ Substance use disorders and problem gambling are linked with multifarious consequences including health concerns,⁴ financial difficulties,^{5 6} stigma, discrimination and isolation.⁷ It is estimated that more than 50% of those seeking services for an addiction are also coping with mental illness,⁸ and many studies have also found that the rates of suicidal ideation, suicide attempts and completed suicides are elevated for individuals with an addiction.^9–11 There is also an increasing awareness of the impact of addictions on individuals and on families with more than 100 million family members affected by a relative’s addiction.¹² The addiction of a family member has many adverse effects for families such as high levels of distress, health problems,^{5 13} family conflict, domestic violence, child maltreatment¹² and financial precarity.^{5 6 12} Studies also report that the health costs for family members coping with the addiction of a significant other are considerably higher than family members who do not have a family member with an addiction.^{5 6} Despite the negative impact on families, addiction treatment has historically focused on the individual.^{14 15} Csiernik¹⁶ described family-focused services as the ‘neglected aspect of addiction treatment’ and other researchers have stated that service providers view family members as ‘adjuncts’ and they are not perceived as an integral part of addiction treatment.¹⁷ This creates a significant barrier to family involvement in addictions.^{15 17 18}

The involvement of family members in routine addiction treatment has been documented as important for two important and inter-related reasons. First, as mentioned previously, families are negatively affected and family-focused services can help reduce the harm to individual family members and to the entire family unit.¹⁹ A second compelling reason for involving families in addiction treatment is that family involvement increases treatment entry, enhances treatment completion and is also linked with better treatment outcomes for the individual coping with the addiction.^20–22 This is relevant when considering the fact that only 20% (or fewer) of individuals with substance use disorders seek treatment,²³ and among problem gambling individuals only 3%–6% seek professional treatment.²⁴ Among those who receive treatment, approximately 50% drop out of treatment and treatment completion is one of the factors most closely associated with positive treatment outcomes.^{25 26} Although studies have documented robust evidence when involving families in addiction treatment, most services target the individual with the addiction and there is little evidence of family-focused approaches in addiction service provisions.¹⁴

Addiction researchers have identified three categories of family interventions: (1) working with family members to promote the entry and engagement in treatment of the individual with the addiction; (2) involving family members in the treatment of the individual with the addiction; and (3) providing services to family members in their own right.^{15 19} There have been a number of substance use studies on the first two categories. For the first category, a few studies have evaluated the Community Reinforcement Approach and Family Training (CRAFT) intervention.^27–29 The CRAFT programme teaches family members coping skills and also facilitates treatment entry for the individual with addiction-related concerns.²⁹ The second category of family interventions has also been studied, but it focuses on conjoint treatment and it has largely targeted spouses (eg, Alcohol Behaviour Couple Therapy).³⁰ The third category concentrates on services given directly to families, and it has received the least attention. While there have been scant studies on this third category of family interventions, a group of UK researchers have developed the stress-strain-coping-support (SSCS) model aimed at reducing the stress and strain to families and increasing support and coping skills.³¹ This approach has been evaluated in a primary care setting and shows promising results.¹³ The SSCS model has similarities to the family psychoeducation approach—an evidence-based practice in mental health and a commonly used family approach for schizophrenia.³² The family psychoeducation literature states that all interventions for families should include the ‘Big Three’, a term that refers to information about the addiction/mental illness, coping skill development and support from peers and professionals. Despite the fact that there has been some research (notably in the first two categories), this is still limited even though the benefits of family involvement and the adverse effects of addictions on families have been documented. In light of the low rates of treatment seeking and high rates of attrition from treatment for individuals with addictions, as well as the pervasive adverse effects of addictions on families, it is critical that family-focused services are available and accessible for all families. The robust research in mental health has demonstrated that the ‘Big Three’ (psychoeducation, support and coping skills) is an evidence-based practice.³² The SSCS model has similar tenets and practices, but requires more research and implementation in policy and practice. Researchers have attributed this neglect to ‘a consequence of the lack of a family orientation in professional training and practice, plus the existence of a number of models of family functioning that cast family members in a negative light.’³³ To our knowledge, there have not been any reviews on family involvement in both substance use and problem gambling treatment for adults.³⁴ Disordered gambling is the only behavioural addiction in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and it is classified with substance use disorders due to their similarities in symptomatology.³⁵ This scoping review will focus on all three forms of family involvement in substance use and gambling treatment to elucidate our understanding of a range of programmes that promote family-focused treatment. It will also identify any gaps in service provisions, as well as barriers to implementation of family-focused practices that have been identified in the literature. This will be an important guide to help move towards best practices for families in addiction treatment. There are currently no clearly identified best practices and this scoping review can be used by both policymakers and clinical settings to develop policies and implement best practices in addiction treatment with various family-focused interventions.

Study objectives

The objectives for this scoping review on family involvement and interventions in addictions are as follows:

• Map and categorise the extent, range and nature of evidence available in peer-reviewed and grey literature examining family interventions in substance use disorders and problem gambling.

• Identify recent family interventions in adult addiction treatment programmes, as well as treatment gaps to guide future research, policy development and service provisions.

Methods and analysis

We will conduct a scoping review to examine the literature on family involvement in addictions using a methodological framework developed by Arksey and O’Malley³⁶ and enhanced by Levac et al.³⁷ A scoping review is suitable for this topic area as it is defined as ‘a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting and synthesizing knowledge.’³⁸ This method includes five stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarising and reporting the results. The aim of this review is for it to serve as a report that can guide the development of best practices for families in addiction treatment.

Stage 1: identifying the research question

Scoping reviews comprise broad research questions as their aim is to synthesise the breadth of evidence on a clearly identified area of inquiry.³⁷ Through consultation with our research team, we developed one broad research question: What are the family interventions or practices that have been implemented and examined in adult addiction treatment? Levac et al³⁷ recommend that researchers define study concepts and target populations in scoping reviews. For this review, we define family broadly to include kin and significant others and this term also includes diverse family members or relationships including, but not limited to, partners, spouses, siblings, friends, adult children and parents. The term addiction encompasses any problematic substance use (alcohol or drugs), as well as problem gambling. Interventions or practices include any method of involving family members in addiction treatment that has been implemented and empirically examined. Treatment refers to any services for an adult coping with an addiction, problematic substance use or problem gambling.

Stage 2: identifying relevant studies

The comprehensive search strategy was developed in collaboration with the study’s principal and coinvestigators (TK and RA), a health sciences librarian at the University of Toronto and the research assistants who will help conduct the scoping review. Relevant studies will be identified by searching the following electronic databases: MEDLINE, PsycINFO and Social Services Abstracts. The researchers selected a cross section of databases that include the range of literature spanning healthcare, psychology, psychiatry, social work and other social sciences. An initial scan of several databases demonstrated that the databases selected were more likely to identify results that are related to the focus of this scoping review. Other databases were not included in this study because the initial scan resulted in thousands of results that were not relevant to the scope of this study. However, to ensure that the scoping review captures the breadth of literature, the research team will also extensively hand-search various reference lists of included studies, key journals, as well as web sites of addiction-related organisations including the Canadian Centre on Substance Use and Addiction (CCSA), Gambling Research Exchange Ontario (GREO), Addiction and the Family International Network (AFINet), and Substance Abuse and Mental Health Services Administration (SAMHSA). The search will cover 2000 up to the present and this limited date range was selected as we are interested in recent addiction treatment approaches involving families in order for this to be most relevant for current treatment programmes. A preliminary search conducted by the research assistant and reviewed by the primary investigator helped refine the search terms and protocol. All literature searches will be completed by a research assistant who will be supervised and guided by the primary investigator (TK). The search includes several terms that relate to these concepts: family, addiction and practice (see table 1).

Table 1.

Search terms for the databases

Concept	Search terms
Family	famil* OR significant other* OR conjoin* OR sibling* OR spous* OR couple* OR partner*
Addiction	addict* OR abus* OR problem* OR misuse OR use* adj2 alcohol OR drug* OR substance OR gambl*
Practice	therap* OR counsel* OR psychotherap* OR psychoeducation* OR (famil* OR psychological OR addiction OR gambl* OR substance* OR alcohol* OR drug* OR group*) adj (interven* OR treatment* OR support OR help OR service*)

Stage 3: study selection

We are following recommendations made by Levac et al³⁷ and will use a transparent, iterative team approach to refine the search strategy and this will be an iterative process to finalise inclusion and exclusion criteria. The review process consists of two stages: first by screening of titles and abstracts and, second, by full-text screening. A research assistant will review using the selection criteria and will be supervised closely by the lead researcher. The research assistant will mark the selections under review with ‘include,’ ‘exclude’ or ‘uncertain’. Levac et al³⁷ noted that it is important to clarify the process of decision-making and we have determined that uncertainties will be discussed with the lead researcher and a third investigator will be included when we cannot reach resolution. The following inclusion criteria will be used to guide the search and will also be used when reviewing articles: (1) study focuses on any type of family involvement or intervention in addiction treatment for family members who have a significant other coping with an addiction; (2) addiction includes alcohol, drugs and gambling at any level of severity; (3) published or unpublished empirical studies that use quantitative, qualitative or mixed methods; (4) written in English or French; and (5) from 2000 onwards. Exclusion criteria that have been identified are: (1) studies that focus on addictions in children or adolescents <18 years of age; (2) literature reviews; and (3) empirical studies that focus on the impact of addiction on family members, but do not examine involvement of family members in treatment.

Stage 4: charting the data

Our data will be charted and sorted according to key themes using a qualitative thematic analysis approach.^{39 40} This is a commonly used method for scoping reviews and it involves identifying themes across the literature and synthesising using summary tables with thematic headings.^{39 40} Charting will be conducted by the research assistant and reviewed by the lead researcher. We will chart extracted data using a data charting form on Excel. Following the recommendation of Daudt et al,⁴¹ we will assign each paper an identifying number which will minimise errors and facilitate tracking of included and excluded articles. We also followed the recommendations by Levac et al³⁷ to make charting an iterative process. The research assistant did a preliminary extraction of 10 articles with some preliminary categories for the chart and the charting was reviewed by the lead researcher. The research team discussed the themes and variables and updated the charting form. The themes and variables that we will be charting include: author, title, peer-reviewed or grey literature paper, country where study was conducted, research aims, methods, sample size, individual with addiction (if specified), family member (if specified), definition of family and family involvement (if provided), addiction type, intervention type, harm reduction or abstinence approach (if specified) and key findings of the study. For key findings, we are specifically searching for a study’s results on family involvement in addiction treatment.

Stage 5: collating, summarising and reporting the results

Levac et al³⁷ suggest that this stage is divided in three distinct steps. With this in mind, our research team will follow these steps in the final stage of the scoping review: (1) analyse extracted data using a numerical summary analysis and qualitative thematic analysis; (2) disseminate the results of the scoping review; and (3) discuss implications for future research, policy and practice.

Ethics and dissemination

This paper presents the protocol for a scoping review of family practices in addiction treatment. Ethics approval is not necessary as the data are collected from publicly available sources. This review will advance knowledge on the ways family members are involved in treatment when a significant other has a substance use or gambling problem. The results will be disseminated through a peer-reviewed journal and will also be reported at local, national and international conferences on addictions and mental health.